Complaint form

Your name *

Your address *

(Postcode)

Your contact details

Home telephone

Work telephone

Mobile telephone

E-mail *

What stage is your complaint? *

Fortunegate's complaints procedure is based on three stages. We need you to tell us which stage of the complaints procedure applies to the complaint you are submitting on this form.

Stage 1 (initial complaint)

Stage 2 (only if Stage 1 previously completed)

Stage 3 (only if Stage 2 previously completed)

What is your complaint about? *

Please give brief details about your complaint, including dates, times, places or names of staff contacted.

What do you think we need to do to put this right? *

Please be as clear as possible when describing what action you think we should take. If you would prefer, please give the contact details of a friend or relative you want us to speak to on your behalf.

Monitoring data

Our aim is to provide its services equally to all. This form helps us monitor the extent to which we are achieving this. Any information you give is strictly confidential.

Note that sections marked with an asterisk (*) must be completed in order to submit the complaint.

Which age range do you fall into? *

How would you describe your household? *

Are you male or female? *

Male

Female

Does anyone in your household have a disability *

No

Yes

What is your ethnic origin? *

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